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Patient Fees DentalPlus ADA Code Description of Services fee ADA Code Description of Services An easy-to-use dental plan. Plan 2 www.azblue.com fee DentalPlus DentalPlus gives you a lot of reasons to smile. DentalPlus covers many basic dental needs. A dental plan that offers affordability and convenience will keep you and your family smiling. The DentalPlus benefit plan includes the following: That’s why Blue Cross Blue Shield of Arizona is pleased to offer DentalPlus, an easy-to-use plan specifically designed to take care of your dental needs. DentalPlus providers are available in Maricopa and Pima counties. Here’s a quick look at the major advantages DentalPlus offers you: w w w w w w No deductibles No claim forms (except for emergencies) No precertification requirements Discounted fees No annual maximums Emergency care Covered Services: Diagnostic Care w Oral examinations and dental X-rays Preventive Care w Teeth cleaning (prophylaxis) w Dietary planning and instruction on plaque control and oral hygiene Services Available for a Fee or a Discount off Billed Charges: Restorations w Regular fillings (silver amalgam, plastic, composite) Periodontics w Treatment of diseases of the gums and bones that support teeth Endodontics w Root canal treatment w Pulpotomy and treatment of dental pulp Oral Surgery w Simple and complicated extractions of the teeth Prosthetics w Crowns, bridges, partial dentures, dentures Orthodontics w Straightening of teeth (for adults and children) Emergency Service w Necessary to control bleeding, relieve pain or eliminate acute infection (limited to $50 reimbursement per occurrence) How DentalPlus works for you. 1 When you sign up for DentalPlus, you’ll be able to select your primary dentist from a list of contracted DentalPlus dentists. The dentist you choose then becomes your primary provider for all your dental needs. If treatment is required that can’t be provided by your primary dentist, you will be referred to a participating DentalPlus specialist. DentalPlus odontic treatment. You may select any one of the DentalPlus orthodontists, and, you will pay the orthodontic fees listed in this brochure’s schedule of covered orthodontic services. Emergency services available too If you have a dental emergency, you should contact your DentalPlus primary dentist first. If you can’t reach your DentalPlus dentist, or you are more than 50 miles from home, you should seek care immediately from any licensed dentist. You will be reimbursed up to $50 for emergency dental treatment. Follow-up care must be administered by your DentalPlus primary dentist. No deductibles and affordable fees. With DentalPlus, there are never any deductibles to pay, and some covered diagnostic and preventive services require no fees. Services available through DentalPlus. Services listed on the fee schedule are available when they are dentally necessary and performed by your DentalPlus primary dentist operating within the scope of his/her practice, provided they are not an excluded service. Blue Cross Blue Shield of Arizona or its designee will interpret whether a service or supply is dentally necessary under the terms of this plan. Patient care is decided between the provider and the patient. Services from a specialist There may be times when your primary dentist will need to refer you, or one of your enrolled dependents, to a specialist for services that cannot be done in his/her office. When you are referred to a DentalPlus specialist, the fee schedule in this brochure will not apply. The DentalPlus specialist will provide services at a 25% discount off his/her own billed charges. This does not apply to orth- Other than this dental emergency care, there are no benefits if you do not use a DentalPlus dentist. Please note that prescription medications are not covered under the DentalPlus Plan. Applying for DentalPlus is easy. Simply fill out the DentalPlus application with all the requested information and follow the instructions on where to send the form. When you enroll in DentalPlus you must select a DentalPlus dentist to be your primary provider of dental care. Be sure to indicate which dentist you have selected on the application. If you are also enrolling your dependents, they must use the same dentist you have selected. DentalPlus is simple to use. After you have received your confirmation of enrollment, you may call your DentalPlus primary dentist for an appointment after your effective date. Be sure to mention that you are a DentalPlus member. After you enroll, you’ll receive your contract/benefit plan booklet, which will describe dental services available through the DentalPlus Plan in greater detail. Please read it carefully for all benefits, exclusions and limitations. 2 DentalPlus DentalPlus: something to smile about. Once you’ve had a chance to use DentalPlus, we’re certain you’ll quickly see how easy it is to care for your dental health — which is something you can definitely smile about. DentalPlus is offered by Blue Cross Blue Shield of Arizona and administered by a dental administrator* contracted with BCBSAZ. Should you have any questions about enrolling in DentalPlus for Individuals, please call Blue Cross Blue Shield of Arizona at (877) 864-4899. For group coverage, please call Blue Cross Blue Shield of Arizona at (602) 864-4260 or (800) 864-4400, extension 4260. Once your DentalPlus coverage becomes effective, please call the DentalPlus administrator at (888) 540-9488 for any questions you have about your coverage. Exclusions and Limitations The following is a partial list of conditions and services that are limited or excluded. A complete listing can be found in the contract/benefit plan booklet, which will be sent to you when you enroll, or prior to enrollment upon request. w w w w w w w w w w w w w w w w w A service not rendered or authorized by your DentalPlus primary dentist, except for emergency treatment Any procedures or services not listed on the DentalPlus Fee Schedule Appliances or restoration necessary to increase vertical dimension or restore an occlusion Complications related to an ineligible or excluded treatment, condition, procedure or service Cosmetic or aesthetic services or surgery Extractions of asymptomatic third molars Orthodontic services or treatment that began before your effective date of coverage or continues after your termination Services or treatment associated with prior orthodontic treatment or services Prescription and over-the-counter drugs Repair or replacement of orthodontic appliances Replacement of lost or stolen denture(s) Services covered by Workers’ Compensation or similar benefits Services or treatment for, or associated with, temporomandibular joint (TMJ) dysfunction or disorder, or for orthognatic surgery Services rendered by a hospital or other facility, or related to a hospital or facility visit Services rendered before your effective date of coverage under this contract or after this coverage terminates Services that are not approved by the American Dental Association (ADA), or those considered investigational or experimental Services that are not dentally necessary, as determined by Blue Cross Blue Shield of Arizona. Important note: This brochure is a general summary. A complete description of any and all benefits, limitations and exclusions is found in and governed by your contract/benefit plan booklet. 3 * DentalPlus is administered by American Dental Professional Services, a separate and independent company contracted with BCBSAZ to provide administrative services. Patient Fees ADA Code Description of Services fee DIAGNOSTIC CARE Clinical oral examinations D0120 Periodic oral evaluation (every 6 months) . . . . . . . $ 0 D0140 Limited oral evaluation – problem focused . . . . . . . . 0 D0150 Comprehensive oral evaluation – new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . 0 D0170 Re-evaluation – limited, problem focused (established patient; not post operative visit) . . . . . . 22 D0180 Comprehensive periodontal evaluation – new or established patient . . . . . . . . . . . . . . . . . . . 36 Radiographs/Diagnostic Imaging (including interpretation) D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0274 D0277 D0310 D0330 Intraoral – complete series (including bitewings) . $11 Intraoral – periapical first film . . . . . . . . . . . . . . . . . 0 Intraoral – periapical each additional film Intraoral – occlusal film . . . . . . . . . . . . . . . . . . . . . 0 Extraoral – first film . . . . . . . . . . . . . . . . . . . . . . . . 0 Extraoral – each additional film . . . . . . . . . . . . . . . . 0 Bitewings – single film . . . . . . . . . . . . . . . . . . . . . . 0 Bitewings – two films . . . . . . . . . . . . . . . . . . . . . . . 0 Bitewings – four films . . . . . . . . . . . . . . . . . . . . . . . 0 Vertical bitewings – 7 to 8 films . . . . . . . . . . . . . . 40 Sialography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Panoramic film . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Test and Examinations D0415 Collection of microorganisms for culture and sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $17 D0416 Viral culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 D0425 Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . 14 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including permalignant and malignant lesions, not to include cytology or biopsy procedures . . . . . . . . . . 25 D0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . 20 D0470 Diagnostic tests . . . . . . . . . . . . . . . . . . . . . . . . . . 50 ADA Code Description of Services fee Other Preventive Services D1310 Nutritional counseling for control of dental disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0 D1330 Oral hygiene instructions . . . . . . . . . . . . . . . . . . . . 0 Preventive sealants for permanent posterior teeth (up to age 19) D1351 Sealant – per tooth . . . . . . . . . . . . . . . . . . . . . . . . 25 Space Maintenance (passive appliances) D1510 D1515 D1520 D1525 D1550 Space maintainer – fixed – unilateral . . . . . . . . . . 157 Space maintainer – fixed – bilateral . . . . . . . . . . . 207 Space maintainer – removable – unilateral . . . . . . 122 Space maintainer – removable – bilateral . . . . . . . 266 Re-cementation of space maintainer . . . . . . . . . . . 34 RESTORATIVE Filings – Amalgam Restorations D2140 D2150 D2160 D2161 Amalgam – one surface, primary or permanent . . $ 44 Amalgam – two surfaces, primary or permanent . . . 57 Amalgam – three surfaces, primary or permanent . . 71 Amalgam – four or more surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Filings – Resin-Based Composite Restorations D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 Resin-based composite – one surface, anterior . . . $ 55 Resin-based composite – two surfaces, anterior . . . 70 Resin-based composite – three surfaces, anterior . . 86 Resin-based composite – four or more surfaces or involving incisal angle (anterior) . . . . . . . . . . . 101 Resin-based composite crown, anterior . . . . . . . . 127 Resin-based composite – one surface, posterior . . . 64 Resin-based composite – two surfaces, posterior . . 82 Resin-based composite – three surfaces, posterior . 105 Resin-based composite – four or more surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Inlay/Onlay Restorations PREVENTIVE CARE Dental Prophylaxis (every 6 months) D1110 Prophylaxis – adult . . . . . . . . . . . . . . . . . . . . . . . . $9 D1120 Prophylaxis – child . . . . . . . . . . . . . . . . . . . . . . . . . 7 Topical Fluoride Treatment (office procedure) D1203 Topical application of fluoride (prophylaxis not included – child) . . . . . . . . . . . . . . . . . . . . . . . . . . 0 D2510 D2520 D2530 D2542 D2543 D2544 D2610 Inlay – metallic – one surfaces . . . . . . . . . . . . . . $310 Inlay – metallic – two surfaces . . . . . . . . . . . . . . . 353 Inlay – metallic – three or more surfaces . . . . . . . 407 Onlay – metallic – two surfaces . . . . . . . . . . . . . . 399 Onlay – metallic – three surfaces . . . . . . . . . . . . . 417 Onlay – metallic – four or more surfaces . . . . . . 434 Inlay – porcelain/ceramic – one surface . . . . . . . . 366 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. 4 Patient Fees ADA Code Description of Services fee RESTORATIVE (Continued) D2620 Inlay – porcelain/ceramic – two surfaces . . . . . . $387 D2630 Inlay – porcelain/ceramic – three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 D2642 Onlay – porcelain/ceramic – two surfaces . . . . . . 400 D2643 Onlay – porcelain/ceramic – three surfaces . . . . . 431 D2644 Onlay – porcelain/ceramic – four or more surfaces . . . . . . . . . . . . . . . . . . . . . 458 D2650 Inlay – resin-based composite – one surface . . . . . 241 D2651 Inlay – resin-based composite – two surfaces . . . . 281 D2652 Inlay – resin-based composite – three or more surfaces . . . . . . . . . . . . . . . . . . . . .301 D2662 Onlay – resin-based composite – two surfaces . . . 275 D2663 Onlay – resin-based composite – three surfaces . . 310 D2664 Onlay – resin-based composite – four or more surfaces . . . . . . . . . . . . . . . . . . . . . 330 Crowns – Single Restoration Only D2710 Crown – resin-based composite (indirect) . . . . . $201 D2712 Crown – resin-based composite (indirect) This code does not include facial veneers . . . . . . . 196 D2720 Crown – resin with high noble metal . . . . . . . . . 458 D2721 Crown – resin with predominantly base metal . . . 429 D2722 Crown – resin with noble metal . . . . . . . . . . . . . 438 D2740 Crown – porcelain/ceramic substrate . . . . . . . . . 469 D2750 Crown – porcelain fused to high noble metal . . . . 463 D2751 Crown – porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 D2752 Crown – porcelain fused to noble metal . . . . . . . 442 D2780 Crown – 3/4 cast high noble metal . . . . . . . . . . . 445 D2781 Crown – 3/4 cast predominantly base metal . . . . 419 D2782 Crown – 3/4 cast noble metal . . . . . . . . . . . . . . . 432 D2783 Crown – 3/4 porcelain/ceramic . . . . . . . . . . . . . 457 D2790 Crown – full cast high noble metal . . . . . . . . . . . 445 D2791 Crown – full cast predominantly base metal . . . . . 423 D2792 Crown – full cast noble metal . . . . . . . . . . . . . . . 431 D2794 Crown – titanium . . . . . . . . . . . . . . . . . . . . . . . 445 Other Restorative Services D2910 Recement inlay, onlay, or partial coverage restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 36 D2915 Recement cast or prefabricated post and core . . . . .36 D2920 Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . 38 D2930 Prefabricated stainless steel crown – primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 D2931 Prefabricated stainless steel crown – permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . 118 D2932 Prefabricated resin crown . . . . . . . . . . . . . . . . . . 128 5 ADA Code Description of Services fee D2933 Prefabricated stainless steel crown with resin window . . . . . . . . . . . . . . . . . . . . . . . . . . $144 D2934 Prefabricated esthetic coated stainless steel crown – primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 D2950 Core buildup, including any pins . . . . . . . . . . . . . 99 D2951 Pin retention – per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 D2952 Cast post and core addition to crown . . . . . . . . . 152 D2953 Each additional cast post – same tooth . . . . . . . . . . 75 D2954 Prefabricated post and core in addition to crown . 125 D2955 Post removal (not in conjunction with endodontic therapy) . . . . . . . . . . . . . . . . . . . . . . . 94 D2957 Each additional prefabricated post – same tooth . . . 63 D2960 Labial veneer (resin laminate) – chairside . . . . . . . 178 D2961 Labial veneer (resin laminate) – laboratory . . . . . . 344 D2962 Labial veneer (porcelain laminate) – laboratory . . . 373 D2971 Additional procedures to construct new crown under existing partial denture framework . . . . . . . . 53 D2975 Coping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 D2980 Crown repair, by report . . . . . . . . . . . . . . . . . . . . 34 D2999 Unspecified restorative procedure, by report . . . . . 56 ENDODONTICS Pulp Capping D3110 Pulp cap – direct (excluding final restoration) . . . $28 D3120 Pulp cap – indirect (excluding final restoration) . . . 21 Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament . . . . . . . $64 D3221 Pulpal debridgement, primary and permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Endodontic Therapy on Primary Teeth D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) . . . . . . $68 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) . . . . . . . 73 Root Canal Therapy (including treatment plan, clinical procedures and follow-up care) D3310 Anterior (excluding final restoration) . . . . . . . . . $271 D3320 Bicuspid (excluding final restoration) . . . . . . . . . . 325 D3330 Molar (excluding final restoration) . . . . . . . . . . . . 429 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. Patient Fees ADA Code Description of Services fee ENDODONTICS (Continued) D3331 Treatment of root canal obstruction; non-surgical access . . . . . . . . . . . . . . . . . . . . . . . $ 92 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth . . . . . . . . . . . . . . 131 D3333 Internal root repair of perforation defects . . . . . . . . 79 ADA Code Description of Services fee PERIDONTICS Surgical Services (including usual postoperative care) D3410 Apicoectomy/periradicular surgery – anterior . . $310 D3421 Apicoectomy/periradicular surgery – bicuspid (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 D3425 Apicoectomy/periradicular surgery – molar (first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 D3426 Apicoectomy/periradicular surgery – each additional root . . . . . . . . . . . . . . . . . . . . . . 113 D3430 Retrograde filling – per root . . . . . . . . . . . . . . . . . 94 D3450 Root amputation – per root . . . . . . . . . . . . . . . . 193 D3460 Endodontic endosseous implant . . . . . . . . . . . . . 552 D3470 Intentional reimplantation (including necessary splinting) . . . . . . . . . . . . . . . . . . . . . . . 380 D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $204 D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78 D4240 Gingival flap procedure, including root planning – four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 339 D4241 Gingival flap procedure, including root planning – one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 175 D4245 Apically positioned flap . . . . . . . . . . . . . . . . . . . . 251 D4249 Clinical crown lengthening – hard tissue . . . . . . . 279 D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 547 D4261 Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces per quadrant . . . . . . . . . . . . . . . . . . . . . . . 285 D4266 Guided tissue regeneration – resorbable barrier, per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 D4267 Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal) . . . 257 D4270 Pedicle soft tissue graft procedure . . . . . . . . . . . . 321 D4271 Free soft tissue graft procedure (including donor site surgery) . . . . . . . . . . . . . . . 416 D4273 Subepithelial connective tissue graft procedures, per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) . . . . . . . . . . . . . . . . 189 D4275 Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . 250 D4276 Combined connective tissue and double pedicle graft, per tooth . . . . . . . . . . . . . . . . . . . . 307 Other Endodontic Procedures Non-surgical Periodontal Services D3910 Surgical procedure for isolation of tooth with rubber dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 49 D3920 Hemisection (including any root removal), not including root canal therapy . . . . . . . . . . . . . 150 D3950 Canal preparation and fitting of preformed dowel or post . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 D4320 Provisional splinting – intracoronal . . . . . . . . . . $206 D4321 Provisional splinting – extracoronal . . . . . . . . . . . 167 D4341 Periodontal scaling and root planning – four or more teeth per quadrant . . . . . . . . . . . . . 111 D4342 Periodontal scaling and root planning – one to three teeth per quadrant . . . . . . . . . . . . . . . 61 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis . . . . . . . . 74 Endodontic Retreatment D3346 Retreatment of previous root canal therapy – anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $366 D3347 Retreatment of previous root canal therapy – bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 D3348 Retreatment of previous root canal therapy – molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 Apexification/recalcification Procedures D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) . . . . . . . . . . . . . . . . . . . . . . $ 99 D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) . . . . . . . . . . . . . 68 D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) . . . . . 217 Apicoectomy/periradicular Services Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. 6 Patient Fees ADA Code Description of Services fee PERIDONTICS (Continued) Other Periodontal Services D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . $65 D4920 Unscheduled dressing change (by someone other than treating dentist) . . . . . . . . 33 D4999 Unspecified periodontal procedure, by report . . . . 17 PROSTHODONTICS (removable) Complete Dentures (including routine post-delivery care) D5110 D5120 D5130 D5140 Complete denture – maxillary . . . . . . . . . . . . . $545 Complete denture – mandibular . . . . . . . . . . . . . 545 Immediate denture – maxillary . . . . . . . . . . . . . . 594 Immediate denture – mandibular . . . . . . . . . . . . . 594 Partial Dentures (including routine post-delivery care) D5211 Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) $459 D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) . 533 D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) . . . . . . . . . . . 601 D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) . . . . . . . . 601 D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth) . . . . . . . . . . 459 D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth) . . . . . . . . . . 533 D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth) . . 351 Adjustments to Dentures D5410 D5411 D5421 D5422 7 Adjust complete denture – maxillary . . . . . . . . . . $31 Adjust complete denture – mandibular . . . . . . . . . 31 Adjust partial denture – maxillary . . . . . . . . . . . . . 31 Adjust partial denture – mandibular . . . . . . . . . . . . 31 ADA Code Description of Services fee Repairs to Complete Dentures D5510 Repair broken complete denture base . . . . . . . . . $60 D5520 Replace missing or broken teeth – complete denture (each tooth) . . . . . . . . . . . . . . . 49 Repairs to Partial Dentures D5610 D5620 D5630 D5640 D5650 D5660 D5670 Repair resin denture base . . . . . . . . . . . . . . . . . . $ 64 Repair cast framework . . . . . . . . . . . . . . . . . . . . . 69 Repair or replace broken clasp . . . . . . . . . . . . . . . 75 Replace broken teeth – per tooth . . . . . . . . . . . . . 53 Add tooth to existing partial denture . . . . . . . . . . . 75 Add clasp to existing partial denture . . . . . . . . . . . 78 Replace all teeth and acrylic on cast metal framework (maxillary) . . . . . . . . . . . . . . . . . . . . 266 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) . . . . . . . . . . . . . . . . . . . 266 Denture Rebase Procedures D5710 D5711 D5720 D5721 Rebase complete maxillary denture . . . . . . . . . . $220 Rebase complete mandibular denture . . . . . . . . . 206 Rebase maxillary partial denture . . . . . . . . . . . . . 182 Rebase mandibular partial denture . . . . . . . . . . . 208 Denture Reline Procedures D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 Reline complete maxillary denture (chairside) . . $125 Reline complete mandibular denture (chairside) . 125 Reline maxillary partial denture (chairside) . . . . . 115 Reline mandibular partial denture (chairside) . . . . 115 Reline complete maxillary denture (laboratory) . . 167 Reline complete mandibular denture (laboratory) 167 Reline maxillary partial denture (laboratory) . . . . 164 Reline mandibular partial denture (laboratory) . . . 164 Interim Prosthesis D5810 D5811 D5820 D5821 Interim complete denture (maxillary) . . . . . . . . $263 Interim complete denture (mandibular) . . . . . . . . 283 Interim partial denture (maxillary) . . . . . . . . . . . . 204 Interim partial denture (mandibular) . . . . . . . . . . 217 Other Removable Prosthetic Services D5850 Tissue conditioning, maxillary . . . . . . . . . . . . . . .$52 D5851 Tissue conditioning, mandibular . . . . . . . . . . . . . . 52 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. Patient Fees ADA Code Description of Services fee PROSTHODONTICS, FIXED Fixed Partial Denture Pontics D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 Pontic – indirect resin based composite . . . . . . . $271 Pontic – cast high noble metal . . . . . . . . . . . . . . 416 Pontic – cast predominantly base metal . . . . . . . . 390 Pontic – cast noble metal . . . . . . . . . . . . . . . . . . 406 Pontic – titanium . . . . . . . . . . . . . . . . . . . . . . . . 419 Pontic – porcelain fused to high noble metal . . . . 410 Pontic – porcelain fused to predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Pontic – porcelain fused to noble metal . . . . . . . . 400 Pontic – porcelain/ceramic . . . . . . . . . . . . . . . . . 436 Pontic – resin with high noble metal . . . . . . . . . . 406 Pontic – resin with predominately base metal . . . . 373 Pontic – resin with noble metal . . . . . . . . . . . . . . 386 Provisional pontic . . . . . . . . . . . . . . . . . . . . . . . 174 Fixed Partial Denture Retainers – Inlays/Onlays D6545 Retainer – cast metal for resin bonded fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $173 D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . 196 D6600 Inlay – porcelain/ceramic, two surfaces . . . . . . . . 343 D6601 Inlay – porcelain/ceramic, three or more surfaces . 359 D6602 Inlay – cast high noble metal, two surfaces . . . . . . 366 D6603 Inlay – cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 402 D6604 Inlay – cast predominantly base metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 D6605 Inlay – cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . .380 D6606 Inlay – cast noble metal, two surfaces . . . . . . . . . 353 D6607 Inlay – cast noble metal, three or more surfaces . . 391 D6624 Inlay - titanium . . . . . . . . . . . . . . . . . . . . . . . . . 366 D6608 Onlay – porcelain/ceramic, two surfaces . . . . . . . 377 D6609 Onlay – porcelain/ceramic, three or more surfaces 389 D6610 Onlay – cast high noble metal, two surfaces . . . . . 395 D6611 Onlay – cast high noble metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 D6612 Onlay – cast predominantly base metal, two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 ADA Code Description of Services fee D6613 Onlay – cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . $410 D6614 Onlay – cast noble metal, two surfaces . . . . . . . . . 388 D6615 Onlay – cast noble metal, three or more surfaces . . 407 D6634 Onlay – titanium . . . . . . . . . . . . . . . . . . . . . . . . 366 Fixed Partial Denture Retainers - Crowns D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6793 Crown – indirect resin based composite . . . . . . $392 Crown – resin with high noble metal . . . . . . . . . 458 Crown – resin with predominantly base metal . . . 434 Crown – resin with noble metal . . . . . . . . . . . . . 442 Crown – porcelain/ceramic . . . . . . . . . . . . . . . . 481 Crown – porcelain fused to high noble metal . . . . 469 Crown – porcelain fused to predominantly bas metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Crown – porcelain fused to noble metal . . . . . . . 448 Crown 3/4 cast high noble metal . . . . . . . . . . . . 442 Crown 3/4 cast predominantly base metal . . . . . 442 Crown 3/4 cast noble metal . . . . . . . . . . . . . . . . 410 Crown 3/4 porcelain/ceramic . . . . . . . . . . . . . . .455 Crown - full cast high noble metal . . . . . . . . . . . 452 Crown – full cast predominantly base metal . . . . . 429 Crown – full cast noble metal . . . . . . . . . . . . . . . 445 Crown – titanium . . . . . . . . . . . . . . . . . . . . . . . 445 Provisional retainer crown . . . . . . . . . . . . . . . . . 161 Other Fixed Partial Denture Services D6920 D6930 D6940 D6950 D6970 Connector bar . . . . . . . . . . . . . . . . . . . . . . . . . $229 Recement fixed partial denture . . . . . . . . . . . . . . 55 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Precision attachment . . . . . . . . . . . . . . . . . . . . . 191 Post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . 153 D6972 Prefabricated post and core in addition to fixed partial denture retainer . . . . . . . . . . . . . . . . . . . . 123 D6973 Core build up for retainer, including any pins . . . . 99 D6975 Coping – metal . . . . . . . . . . . . . . . . . . . . . . . . . 230 D6976 Each additional indirectly fabricated post – same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 64 D6977 Each additional prefabricated post – same tooth . . . 62 D6980 Fixed partial denture repair, by report . . . . . . . . . 57 D6985 Pediatric partial denture, fixed . . . . . . . . . . . . . . . 209 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. 8 Patient Fees ADA Code Description of Services fee ORAL AND MAXILLOFACIAL SURGERY Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7111 Extraction – coronal remnants – deciduous tooth . . . . . . . . . . . . . . . . . . . . . . . . . $41 D7140 Extraction – erupted tooth or exposed root (elevation and/or forceps removal) . . . . . . . . . . . . 56 Surgical Extractions (includes local anesthesia, suturing if needed, and Routine Postoperative Care) D7210 Surgical removal of erupted tooth requiring elevation or mucoperiosteal flap and removal of bone and/or section of tooth . . . . . . . . . . . . . . . . . . . . . . . . . $ 96 D7220 Removal of impacted tooth – soft tissue . . . . . . . 119 D7230 Removal of impacted tooth – partially bony . . . . 160 D7240 Removal of impacted tooth – completely bony . . 188 D7241 Removal of impacted tooth – completely bony, with unusual surgical complications . . . . . . . . . . . 236 D7250 Surgical removal of residual tooth roots (cutting procedure) . . . . . . . . . . . . . . . . . . . . . . . 101 Other Surgical Procedures D7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . $332 D7261 Primary closure of a sinus perforation . . . . . . . . . 273 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth . . . . . . . . . 194 D7280 Surgical access of an unerupted tooth . . . . . . . . . 174 D7282 Mobilization of erupted or malpositioned tooth to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 D7283 Placement of device to facilitate eruption of impacted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 D7285 Biopsy of oral tissue – hard (bone, tooth) . . . . . . . 150 D7286 Biopsy of oral tissue – soft . . . . . . . . . . . . . . . . . . 150 D7287 Exfoliative cytological sample collection . . . . . . . . 80 D7288 Brush biopsy – transepithelial sample collection . . . 40 Alveoloplasty – Surgical Preparation of Ridge for Dentures D7310 Alveoloplasty in conjunction with extractions – per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . $112 D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces – per quadrant . . 89 D7320 Alveoloplasty not in conjunction with extractions – per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . .137 D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant . . 136 Vestibuloplasty 9 ADA Code Description of Services fee D7340 Vestibuloplasty – ridge extension (secondary epithelialization) . . . . . . . . . . . . . . . $320 D7350 Vestibuloplasty – ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) . . . . . . . . . 843 Surgical Excision of Soft Tissue Lesions D7410 D7411 D7412 D7413 D7414 D7415 D7465 Excision of benign lesion up to 1.25 cm . . . . . . $110 Excision of benign lesion greater than 1.25 cm . . 261 Excision of benign lesion, complicated . . . . . . . . 306 Excision of malignant lesion up to 1.25 cm . . . . . 233 Excision of malignant lesion greater than 1.25 cm . 344 Excision of malignant lesion, complicated . . . . . . 361 Destruction of lesions by physical or chemical method, by report . . . . . . . . . . . . . . . . . . . . . . . . 83 Surgical Excision of Intra-osseous Lesions D7440 Excision of malignant tumor – lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . $228 D7441 Excision of malignant tumor – lesion diameter greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . 339 D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . 169 D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm . . . . . . . . . . 217 D7460 Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . 123 D7461 Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm . . . . . . . . . . 172 Excision of Bone Tissue D7471 D7472 D7473 D7485 D7490 Removal of lateral exostosis (maxilla or mandible) . 277 Removal of torus palatinus . . . . . . . . . . . . . . . . . 388 Removal of torus mandibularis . . . . . . . . . . . . . . 407 Surgical reduction of osseous tuberosity . . . . . . . . 317 Radical resection of maxilla or mandible . . . . . . 2,980 Surgical Incision D7510 Incision and drainage of abscess – intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . $ 83 D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 D7520 Incision and drainage of abscess – extraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . 150 D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) . . . . . . . . . . . . . . . . . . 359 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. Patient Fees ADA Code Description of Services fee ORAL AND MAXILLOFACIAL SURGERY(Con’t) D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue . . . . . . . . . . . . . $104 D7540 Removal of reaction producing foreign bodies, musculoskeletal system . . . . . . . . . . . . . . . . . . . . 128 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone . . . . . . . . . . . . . . . . . . . . . . . . 127 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body . . . . . . . . . . . . . . . . . . 406 Treatment of Fractures – Simple D7610 Maxilla – open reduction (teeth immobilized, if present . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,627 D7620 Maxilla – closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,220 D7630 Mandible – open reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,115 D7640 Mandible – closed reduction (teeth immobilized, if present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,220 D7650 Malar and/or zygomatic arch – open reduction . 1,018 D7660 Malar and/or zygomatic arch – closed reduction . 599 D7670 Alveolus – closed reduction may include stabilization of teeth . . . . . . . . . . . . . . . . . . . . . . 381 D7671 Alveolus – open reduction, may include stabilization of teeth . . . . . . . . . . . . . . . . . . . . . 1,021 D7680 Facial bones – complicated reduction with fixation and multiple surgical approaches . . . . . . 3,051 Treatment of Fractures – Compound D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7771 D7780 Maxilla – open reduction . . . . . . . . . . . . . . . . $1,912 Maxilla – closed reduction . . . . . . . . . . . . . . . . 1,326 Mandible – open reduction . . . . . . . . . . . . . . . . 2,274 Mandible – closed reduction . . . . . . . . . . . . . . . 1,369 Malar and/or zygomatic arch – open reduction . . 1,740 Malar and/or zygomatic arch – closed reduction . . 766 Alveolus – open reduction stabilization of teeth . . . 805 Alveolus – closed reduction stabilization of teeth . . 754 Facial bones – complicated reduction with fixation and multiple surgical approaches . . . . . . 3,982 Repair of Traumatic Wounds D7910 Suture of recent small wounds up to 5 cm . . . . . $117 Complicated Suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) ADA Code Description of Services fee Other Repair Procedures D7920 Skin graft (identify defect covered, location and type of graft) . . . . . . . . . . . . . . . . . . . . . . $1,199 D7960 Frenulactomy (frenectomy or frenotomy) – separate procedure . . . . . . . . . . . . . . . . . . . . . . . . 99 D7963 Frenuloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 D7970 Excision of hyperplastic tissue – per arch . . . . . . . 169 D7971 Excision of pericoronal gingiva . . . . . . . . . . . . . . . 78 D7972 Surgical reduction of fibrous tuberosity . . . . . . . . 139 D7980 Sialolithotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 217 D7981 Excision of salivary gland, by report . . . . . . . . . . 558 D7982 Sialodochoplasty . . . . . . . . . . . . . . . . . . . . . . . . . 610 D7983 Closure of salivary fistula . . . . . . . . . . . . . . . . . . 228 D7990 Emergency tracheotomy . . . . . . . . . . . . . . . . . . . 406 D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar) . . . . . . . . 125 ORTHODONTICS Orthodontic PLAN benefits cover 24 months of usual and customary orthodontic treatment. You are responsible to pay for initial diagnostic workup, X-rays and retention Limited Orthodontic Treatment D8010 Limited orthodontic treatment of the primary dentition . . . . . . . . . . . . . . . . . . . . . . $1,080 D8020 Limited orthodontic treatment of the transitional dentition . . . . . . . . . . . . . . . . . . . . . 1,050 D8030 Limited orthodontic treatment of the adolescent dentition . . . . . . . . . . . . . . . . . . . . . 1,080 D8040 Limited orthodontic treatment of the adult dentition . . . . . . . . . . . . . . . . . . . . . . . . . . 984 Interceptive Orthodontic Treatment D8050 Interceptive orthodontic treatment of the primary dentition . . . . . . . . . . . . . . . . . . . . . . $1,132 D8060 Interceptive orthodontic treatment of the transitional dentition . . . . . . . . . . . . . . . . . . . . 1,139 Comprehensive Orthodontic Treatment D8070 Comprehensive orthodontic treatment of the transitional dentition . . . . . . . . . . . . . . . . . $2,273 D8080 Comprehensive orthodontic treatment of the adolescent dentition . . . . . . . . . . . . . . . . . . 2,544 D8090 Comprehensive orthodontic treatment of the adult dentition . . . . . . . . . . . . . . . . . . . . . . 2,632 D7911 Complicated suture – up to 5 cm . . . . . . . . . . . . $ 56 D7912 Complicated suture – greater than 5 cm . . . . . . . 320 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. 10 Patient Fees ADA Code Description of Services fee ADJUNCTIVE GENERAL SERVICES ADA Code Description of Services fee Professional Consultation Unclassified Treatment D9310 Consultation by dentist or physician other than requesting dentist or physician . . . . . . . . . . . . . . $44 D9110 Palliative (emergency) treatment of dental pain – minor procedure . . . . . . . . . . . . . . . . . . . . . . . . $35 Professional Visits Anesthesia D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 Regional block anesthesia . . . . . . . . . . . . . . . . . . $ 24 Trigeminal division block anesthesia . . . . . . . . . . . 48 Local anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Deep sedation/general anesthesia – first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . 137 Deep sedation/general anesthesia – each additional 15 minutes . . . . . . . . . . . . . . . . . . 57 Analgesia, anxiolysis, inhalation of nitrous oxide . . 19 Intravenous conscious sedation/analgesia – first 30 minutes . . . . . . . . . . . . . . . . . . . . . . . . . 108 Intravenous conscious sedation/analgesia – each additional 15 minutes . . . . . . . . . . . . . . . . . . 46 Non-intravenous conscious sedation . . . . . . . . . . . 42 D9440 Office visit – after regularly scheduled hours . . . . $44 Miscellaneous Services D9910 Application of desensitizing medicament . . . . . . . $ 13 D9911 Application of desensitizing resin for cervical and/or root surface, per tooth . . . . . . . . . . 22 D9930 Treatment of complications (post-surgical)unusual circumstances, by report . . . . . . . . . . . . . . 39 D9951 Occlusal adjustment – limited . . . . . . . . . . . . . . . . 28 D9952 Occlusal adjustment – complete . . . . . . . . . . . . . 170 D9999 Unspecified adjunctive procedure, by report . . . . . 28 11-0115 Fees listed apply only when services are performed by your DentalPlus primary dentist. If referred to a DentalPlus specialist, services will be provided at a 25% discount off the specialist’s billed charges. D2613 0108 2613 0211